Sarasota County Contractor Licensing Contractor Registration Form Page 3
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3Sarasota County Contractor Licensing
Agent Authorization Form
South County:
North County:
Planning and Development Services Business Center
Planning and Development Services Business Center
4000 Tamiami Trail S. Room 122
1001 Sarasota Center Blvd
Venice, Florida 34293-5076
Sarasota, Florida 34240
THIS LETTER SUPERCEDES ANY PREVIOUSLY SUBMITTED LETTER OF AUTHORIZATION & MUST BE NOTORIZED
Please return to:
Attn: Contractor Licensing, 1001 Sarasota Center Blvd, Sarasota FL 34240; Fax (941) 861-6711 or
Email
Licensing@scgov.net
ATTENTION: Agent must attach a copy of their Driver’s License or State I.D. card with this application.
__NEW AGENT OR __UPDATE EXISTING AGENT
I, _____________________________________________, of _______________________________________________
(Print License Holder’s Name)
(Print Business Name)
authorize __________________________________to act as my agent under my license _________________________
(Print Agent’s Legal Name)
(License Number)
for the following time period (not to exceed one year) ___________________________to__________________________
(MM/DD/YYYY)
(MM/DD/YYYY)
I understand that I, as the licensed qualifier, am solely responsible for any permit submitted or obtained by my agent and
that if I terminate my agent authorization I must notify the building department in writing to request removal of agent from
my account and that Sarasota County Ordinance 2002-079 section 22-124 (B) states: Contractors may designate an
agent to sign permit applications for a specific time frame, not to exceed one (1) year; authority for such action shall be a
notarized letter designating the agent sent to the Development Services Business Center.
License Holder’s Signature: ___________________________________
STATE OF FLORIDA COUNTY OF ____________________________
The foregoing instrument was acknowledged before me this ____day of ____________, 20____, by
____________________________________________.
_____________________________________________
LICENSE HOLDER’S NAME PRINTED
NOTARY SIGNATURE
___Personally Known OR ___Produced Identification
NOTARY STAMP
Type of Identification Produced ___________________________
Agent Name: __________________________________________ Phone: ________________ Fax: ________________
Mailing Address: ___________________________________________________________________________________
Agent E-mail: _____________________________________________________________________________________
LIC05 Agent Authorization Form – Revised 8/23/13
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